Original articleDoes Surgical Technique Influence Post-Tonsillectomy Haemorrhage? Our Experience¿Influye la técnica quirúrgica en las hemorragias postamigdalectomía? Nuestra experiencia☆
Introduction
Tonsillectomy is one of the oldest and most common procedures performed by ENT specialists. The indications for it, although they have changed through the years, cover both children and adults. These indications include chronic or recurring tonsillitis and to treat sleep apnoea/hypopnoea syndrome (SAHS).1, 2
Throughout history surgical techniques for tonsillectomy have varied. Changes have been made in line with the reduction in intra- and post-operative complications, lower short-term morbidity and shorter operating times, amongst others. However, to date, no technique appears to be clearly superior.3
Despite being generally considered low-risk surgery, tonsillectomy has the potential for extensive complications, of which postoperative haemorrhage is the most common.2, 4, 5, 6, 7
For this reason, the main objective of this study was to determine, according to our experience, the prevalence of this postoperative complication and to evaluate whether the technique used has an influence on its onset.
According to literature, the frequency of onset varies considerably depending on the author, ranging from 1.5% to 20%.1, 2, 5, 7, 8, 9, 10, 11 According to Sheshamani,3 the post-tonsillectomy bleed rate in a study which only included adults was 6%. Walker et al., in a prospective study which analysed 1133 tonsillectomies,8 observed that 4.5% of the patients presented with this complication. Monopolar forceps dissection presented a lower postoperative haemorrhage rate compared with cold dissection followed by coagulation, but presented a greater risk of surgical reintervention and blood transfusion.
Various surgical dissection techniques are used currently, from the traditional cold dissection, to different “hot” techniques, such as Colorado needle, coblator, electrocautery (monopolar and bipolar forceps), microdebrider, amongst others. Different techniques are also used to achieve haemostasis of the tonsil bed; these include gauze compression, coagulation with monopolar or bipolar forceps, suturing of pillars, coblator, etc.
In a study which compared the onset of haemorrhage after dissection by coblation and by electrocautery in 90 patients, only one episode of bleeding was encountered which occurred in a patient operated using electrocautery.12
In the study performed by Gallaher et al. which compared the onset of postoperative bleeding in 4776 patients, after dissection techniques using electrocautery, coblator and microdebrider, a haemorrhage rate of 1.7% was observed; the most frequent being after electrocautery (1.9%).1
Comparing dissection by electrocautery and cold dissection, it can be concluded from the study performed by Lee et al.13 that, out of 337 patients, the postoperative bleed rate in adults operated using electrocautery was 12%, compared with those operated using cold dissection (5.5%). For children the haemorrhage rate in both groups was not statistically significant.
In the National Prospective Tonsillectomy Audit (NPT)11 which compared 33,921 tonsillectomies performed using different surgical techniques, it can be seen that the lowest bleed rate was obtained with cold dissection with suturing of the pillars (.17%), followed by cold dissection and haemostasis with bipolar forceps (2.7%) and with monopolar forceps (2.9%). Bipolar forceps present a greater risk of bleeding at 4.6%, a similar percentage to that of the coblator. According to this study, the technique with the poorest results in terms of postoperative haemorrhage rate is dissection with monopolar forceps (6.6%).
In a meta-analysis which included 3384 patients,9 it was observed that the prevalence of post-tonsillectomy haemorrhage was around 3.3%. Evans and Khan performed a study which used telephone interviews with post-tonsillectomy patients and found that 40% of the patients had experienced some type of bleeding, however only 8% required admission to hospital and 3% required surgical reintervention.14
According to Blakley, the maximum acceptable post-tonsillectomy haemorrhage rate is 13.9%. However, rates have been reported in literature that vary in a range from 18% and 20%. This author considers that rates up to 5% are reasonable and those exceeding 14% should be monitored and their causes examined.10
Other secondary objectives in our study were to observe the relationship between post-tonsillectomy haemorrhage and the patient's age, the need for reintervention, the time elapsing between surgery and the onset of the complication and also the association with the preoperative diagnosis, and therefore, with the surgical indication.
Section snippets
Methods
This is a retrospective cross-sectional study, with a study period of 21 months (April 2012 to January 2014, inclusive).
The statistical study was performed with Chi-squared and Fisher's tests according to the sample size for the qualitative variables and Student's t-test for paired data and the Kruskal Wallis test for analysing the quantitative and qualitative variables, according to the sample size. 95% was taken as statistical significance.
429 tonsillectomy cases were included, accompanied or
Results
428 cases underwent tonsillectomy, accompanied or otherwise by adenoidectomy. Cold dissection was the technique used on 168 patients, Colorado needle dissection was used for 212 and the rest, i.e., 49 cases, dissection with monopolar forceps. Therefore, Colorado needle was used in almost half the patients.
Of the total number of tonsillectomies, 30 patients presented with postoperative haemorrhage, which represents a post-tonsillectomy haemorrhage rate of 6.99%.
Of these 30 patients presenting
Discussion
Although tonsillectomy is a common operation in the ENT specialist's usual practice, much effort has been made to study, analyse and even to develop the different surgical techniques available to us today.
The most relevant aspect of the operation and the one which is of most concern to surgeons is probably the post-tonsillectomy haemorrhage rate.
We obtained a post-tonsillectomy haemorrhage rate in this study of 6.99%. In most of the literature we consulted this rate is between 1% and 5%.11, 12
Conclusions
We conclude in our study that the surgical technique with the lowest postoperative haemorrhage rates is cold dissection with haemostasis by monopolar forceps. On the other hand, monopolar forceps dissection is the technique with the highest rates of bleeding; these results are statistically significant.
Adult patients and patients with a preoperative diagnosis of peri-tonsillar abscess and chronic tonsillitis are at greatest risk of presenting with an episode of haemorrhage, according to our
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Please cite this article as: Betancourt AR, López C, Zerpa V, Carrasco M, Dalmau J. ¿Influye la técnica quirúrgica en las hemorragias postamigdalectomía? Nuestra experiencia. Acta Otorrinolaringol Esp. 2015;66:218–223.